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Section 2
Motivations for Self-Injury in an Adolescent Inpatient Population:
Development of a Self-Report Measure

Question 2 | Test | Table of Contents

Self-injury may be defined as the deliberate destruction or alteration of body tissue without suicidal intent [1] and is common in borderline personality disorder (BPD) in adults. [2] Self-injury has been linked with post-traumatic stress disorder (PTSD), dissociative identity disorder, bipolar disorder, depression, [3,4] adjustment disorder, and substance abuse/ dependence. [3-5]

Distressing emotions such as feelings of rejection, abandonment, [15-17] depersonalization, resentment, rage, [18] loneliness, depression, and non-specific emotional pain [19] may precede self-injury. It remains unclear as to why people engage in self-injury to manage distressing emotions, although early childhood sexual abuse is often cited as a factor. [20] Osuch et al. created the Self-Injury Motivation Scale (SIMS) to explore reasons for self-injury. [21] It is a 35-item self-report measure designed to determine, from the patient’s perspective, reasons for self-injury.

Aims

The aims of this study were to modify and trial the SIMS in an adolescent inpatient population, ascertain the methods utilized to self-injure, determine the motivations for self-injury, and establish the diagnoses associated with self-injury in this sample.

Materials
The Self-Injury Interview

The Self-Injury Interview (SII) [21] is an 8-item semi structured interview collecting information on self-injury practice, method and frequency. The SII used in the current study was modified from its original version, with permission being granted by its author, Dr Elizabeth Osuch. It takes between 5 and 15 minutes to complete. A mental health nurse known to the patient completed the SII with the patient during a clinical interview. Clinical diagnosis and length of admission were obtained from the patient’s file. 

Procedure

Suitable participants were invited by nursing staff to take part in the study at least 72 hours after initial admission. If the patient expressed interest, written informed consent was sought from the parent or guardian. Exclusion criteria were: (i) failure to gain written consent form the parent/guardian and/or participant, (ii) inpatient’s considered too unwell to participate in the study, (iii) patients with intellectual disability, and (iv) patients who were hearing-impaired.

Results

There were 28 females and 10 males. Mean age for females was 15.7 years (SD = 1.0 years; range 14-17 years), mean age for males was 16.1 years (SD = 0.9 years; range 15-17 years). Twenty-two adolescents (58%; 16 females and six males) had a diagnosis of mood disorder (14 depression, six dysthymia), seven females had a diagnosis of post-traumatic stress disorder (PTSD), and five females and one male had a diagnosis of an eating disorder.

Age of onset of self-injury was lower in females (mean = 14.0 years; SD = 1.0 years) compared to males (mean = 14.5 years; SD = 1.1 years), and frequency of self-injury was higher among females (mean of ‘‘more than 12 times per year’’) compared to males (mean of ‘‘6-12 times per year’’). Some females could not remember how many times they had self-injured, while all males could remember.

Discussion

We describe a modified self-report instrument that measures the motivations for self-harm in adolescents. Clinicians’ impressions were that the SIMS-A was a useful and well-tolerated instrument in an adolescent inpatient population.

In order to determine the similarity of the SIMS-A to the original adult version of the SIMS, a factor analysis was conducted. The factor analysis revealed four factors: (i) emotion regulation, (ii) communicating to/influencing others, (iii) punishment/excitement, and (iv) psychoses/lack of insight.

In this sample, females tended to have a more severe presentation than males, with a lower mean age, longer mean admission time, lower age of onset for self-injury, and more frequent episodes of self-injury. For males and females combined, depression was the most frequent diagnosis followed by PTSD. The methods used to self-injure were similar in males and females. Combining males and females, the four most frequent methods of self-injury were hitting, cutting, scratching and burning.

This result is consistent with the adult literature, where the four most frequent methods of self-injury were cutting/scratching, hitting self or objects, burning and substance abuse. [21] There were few overdoses recorded in this sample because overdose was not included in the protocol definition of self-injury, and therefore patients were not invited to participate if it was known that they had overdosed but not self-injured.

Among the sample, the most popular reason for self-injury, among both male and female patients, was to distract from emotional pain by experiencing physical pain. This motivation is consistent with reports in the adult literature and follows the hypothesis that self-injury is done to regulate emotion. The second most popular motivation was to punish the self for being bad. This particular motivation highlights the low self-esteem seen in many adolescents who self-injure, [22] and possibly indicates a high use of violence within the adolescent’s environment.

There were high rates of non-involvement by potential subjects because we were unable to place a researcher on the adolescent unit to recruit participants and administer the questionnaires. Therefore, we relied on unit nurses to assist us, in addition to their usual duties. Furthermore, the acute nature of the inpatient population made it difficult to obtain written parental consent. Therefore, it is possible that the sample obtained was not representative of self-injuring patients attending the adolescent unit over the period of the study.

- Swannell, S; Matin, G; Scott, J; Gibbons, M; Gifford, S; Motivations for Self-Injury in an Adolescent Inpatient Population: Development of a Self-Report Measure. Australian Psychiatry; April 2008, 16(2); (98-103)  doi: 10.1080/10398560701636955

Personal Reflection Exercise #2
The preceding section contained information about motivations for self-injury in an adolescent inpatient population. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Predictors of repeated adolescent self-harm: The display
of multiple variables and mediators in a 2-year study

- Huang, Y. H., Liu, H. C., Sun, F. J., & Liu, S. I. (2022). Predictors of repeated adolescent self-harm: The display of multiple variables and mediators in a 2-year study. Journal of the Formosan Medical Association = Taiwan yi zhi, 121(12), 2584–2592. https://doi.org/10.1016/j.jfma.2022.08.019


Peer-Reviewed Journal Article References:
Knutson, D., Jacobs, S. C., Hakman, M., & Milton, D. C. (2021). Profiles of distress and self-harm among LGBTQ+ transitional youth in a rural state. Journal of Rural Mental Health, 45(2), 107–120.

Sansone, R. A., Sellbom, M., & Songer, D. A. (2018). Borderline personality disorder and mental health care utilization: The role of self-harm. Personality Disorders: Theory, Research, and Treatment, 9(2), 188–191.

Witt, K., & Robinson, J. (2019). Sentinel surveillance for self-harm: Existing challenges and opportunities for the future [Editorial]. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 40(1), 1–6.

QUESTION 2
What was the Self-Injury Motivation Scale designed to determine? To select and enter your answer go to Test.

Excerpt of Bibliography referenced in this article

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